CELLULITIS, PERIORBITAL

Fozia Akhtar Ali, MD • Mohammad Ansar Mughal, MD

 BASICS

DESCRIPTION

•  An acute bacterial infection of the skin and subcutaneous tissue anterior to the orbital septum; not involving the orbital structures (globe, fat, and ocular muscles)

•  Synonym(s): preseptal cellulitis

ALERT

It is essential to distinguish periorbital cellulitis from orbital cellulitis. Orbital cellulitis is a potentially life-threatening condition. Orbital cellulitis is posterior to the orbital septum; symptoms include restricted eye movement, pain with eye movement, proptosis, and vision changes.

EPIDEMIOLOGY

•  Occurs more commonly in children; mean age 21 months

•  3 times more common than orbital cellulitis (1)[C]

Incidence

•  Increased incidence in the winter months (due to increased cases of sinusitis) (1)[C]

ETIOLOGY AND PATHOPHYSIOLOGY

•  The anatomy of the eyelid distinguishes periorbital (preseptal) from orbital cellulitis:

–  A connective tissue sheet (orbital septum) extends from the orbital bones to the margins of the upper and lower eyelids; it acts as a barrier to infection deep in the orbital structures.

–  Infection of tissues anterior to the orbital septum is periorbital (preseptal) cellulitis.

–  Infection deep to the orbital septum is orbital (postseptal) cellulitis.

•  Periorbital cellulitis classically arises from a contiguous infection of soft tissues of the face.

–  Sinusitis (via lamina papyracea) extension

–  Local trauma; insect or animal bites

–  Foreign bodies

–  Dental abscess extension

–  Hematogenous seeding

•  Common organisms (1)[C]

–  Staphylococcus aureus, typically MSSA (MRSA is increasing)

–  Staphylococcus epidermidis

–  Streptococcus pyogenes

•  Atypical organisms

–  Acinetobacter sp.; Nocardia brasiliensis

–  Bacillus anthracis; Pseudomonas aeruginosa

–  Neisseria gonorrhoeae; Proteus sp.

–  Pasteurella multocida; Mycobacterium tuberculosis; Trichophyton sp. (ringworm)

•  Since vaccine introduction, the incidence of Haemophilus influenzae has decreased. This organism should still be suspected in unimmunized or partially immunized patients.

Genetics

No known genetic predisposition.

RISK FACTORS

•  Contiguous spread from upper respiratory infection

•  Sinusitis

•  Local skin trauma/puncture wound

•  Insect bite

•  Bacteremia

GENERAL PREVENTION

•  Avoid dermatologic trauma around the eyes.

•  Avoid swimming in fresh or salt water with facial skin abrasions.

•  Routine vaccination: particularly H. influenzae type B and Streptococcus pneumoniae

 DIAGNOSIS

HISTORY

•  Induration, erythema, warmth, and/or tenderness of periorbital soft tissue, usually with normal vision and normal eye movements

•  Chemosis (conjunctival swelling), proptosis; pain with extraocular eye movements can occur in severe cases of periorbital cellulitis, although these symptoms are more common with (and concerning for) orbital cellulitis.

•  Fever (not always present)

ALERT

Pain with eye movement, fever, and conjunctival swelling raise the suspicion for orbital cellulitis.

PHYSICAL EXAM

•  Vital signs and general appearance. (Patients with orbital cellulitis often appear systemically ill.)

•  Thorough inspection of the eye and surrounding structures—lids, lashes, conjunctiva, and skin

•  Erythema, swelling, and tenderness of lids without orbital congestion

–  Violaceous discoloration of eyelid is more commonly associated with H. influenzae.

•  Evaluate for any skin break.

•  Look for vesicles to rule out herpetic infection.

•  Inspect nasal vaults and palpate sinuses for signs of acute sinusitis.

•  Examine oral cavity for dental abscesses.

•  Test ocular motility and visual acuity.

DIFFERENTIAL DIAGNOSIS

•  Orbital cellulitis

–  Orbital cellulitis may have the same signs and symptoms as periorbital cellulitis, with more extensive proptosis, chemosis, ophthalmoplegia, decreased visual acuity, or fever.

•  Abscess

•  Dacryocystitis

•  Hordeolum (stye)

•  Allergic inflammation

•  Orbital or periorbital trauma

•  Idiopathic inflammation from orbital pseudotumor

•  Orbital myositis

•  Rapidly progressive tumors

–  Rhabdomyosarcoma

–  Retinoblastoma

–  Lymphoma

•  Leukemia

DIAGNOSTIC TESTS & INTERPRETATION

Initial Tests (lab, imaging)

•  CBC with differential

•  Blood cultures (low yield) (2)[C]

•  Wound culture of purulent drainage (if present)

•  Imaging is indicated if there is suspicion for orbital cellulitis (marked eyelid swelling, fever, and leukocytosis or those who fail to improve on appropriate antibiotics in 24 to 48 hours).

•  CT can evaluate the extent of infection and detect orbital inflammation or abscess (3)[B]:

–  The classic sign of orbital cellulitis on CT scan is bulging of the medial rectus.

–  CT should be performed with contrast, thin sections (2 mm); coronal and axial views with bone windows.

Follow-Up Tests & Special Considerations

•  Children with periorbital or orbital cellulitis often have underlying sinusitis.

•  If a child is febrile, <15 months old, and appears toxic, admit for blood cultures, antibiotic therapy, and consider lumbar puncture.

 TREATMENT

MEDICATION

•  Empiric antibiotic treatment to cover the most likely organisms (Staphylococcus and Streptococcus) (3)[C]

•  Observe local prevalence of MRSA to determine need for coverage therapy.

•  No evidence that IV antibiotics are more effective than PO in reducing recovery time or preventing secondary complications in the management of simple periorbital cellulitis (1)[C].

•  No evidence for steroid use

First Line

•  Uncomplicated posttraumatic

–  Usually due to skin flora, including Staphylococcus and Streptococcus

–  Cephalexin 500 mg PO q6h or dicloxacillin 500 mg PO q6h

–  Clindamycin 300 mg PO TID, doxycycline 100 mg PO BID, or trimethoprim-sulfamethoxazole (TMP-SMX) 1 to 2 DS tablets PO q12h if MRSA is suspected.

•  Extension from sinusitis

–  Amoxicillin-clavulanate 875 mg PO BID

–  3rd-generation cephalosporin (e.g., cefdinir 300 mg PO BID)

•  Dental abscess

–  Amoxicillin-clavulanate 875 mg PO BID or clindamycin 300 mg PO TID

•  Bacteremic cellulitis

–  May be associated with meningitis

–  Ceftriaxone 1 g IV q24h plus vancomycin 15 mg/kg/dose IV q8–12h or clindamycin 600 to 900 mg IV q8h to cover MRSA

•  Duration of therapy should be 7 to 10 days

–  If symptoms do not improve within 24 hours, IV antibiotic therapy is indicated.

ISSUES FOR REFERRAL

Consult ENT and ophthalmology if there is concern of orbital cellulitis or when 1st-line treatment has failed (4).

SURGERY/OTHER PROCEDURES

•  Usually not indicated in uncomplicated cases

•  If there is an abscess or potential compromise of critical structures, orbital surgery is indicated.

•  Diplopia is the strongest clinical predictor of surgery.

ADMISSION, INPATIENT, AND NURSING CONSIDERATIONS

•  Mild cases in adults and children >1 year of age can be managed on an outpatient basis, if the patient is stable and there are no systemic signs of toxicity.

•  Consider hospitalization and IV antibiotics:

–  If patient appears systemically ill

–  Children <1 year of age (4,5)[C]

–  Patients not immunized against S. pneumoniae or H. influenzae

–  If no signs of clinical improvement are apparent after 24 hours of antibiotic therapy

–  Cases with high suspicion of orbital cellulitis (eyelid swelling with reduced vision, diplopia, abnormal light reflexes, or proptosis)

•  No strict guidelines indicate when to switch from parenteral to PO therapy. In general, switch to PO therapy after the patient is afebrile and the skin findings have begun to resolve (typically 2 to 3 days).

•  Continue therapy for 10 to 14 days for orbital cellulitis or complicated periorbital cellulitis.

 ONGOING CARE

FOLLOW-UP RECOMMENDATIONS

Patient Monitoring

Follow for signs of orbital involvement, including decreased visual acuity or painful/limited ocular motility.

PATIENT EDUCATION

•  Maintain good skin hygiene.

•  Avoid skin trauma.

•  Report early skin changes (swelling, redness, and pain) if recurrent after a course of therapy.

PROGNOSIS

•  With timely treatment, patients do well.

•  A 10-day course of antibiotics is generally sufficient.

•  Recurrent periorbital cellulitis occurs with ≥3 periorbital infections in 1 year with at least 1 month of in between episodes; must be differentiated from treatment failure due to antibiotic resistance (1)[C].

COMPLICATIONS

•  Orbital cellulitis; orbital abscess formation

•  Scarring

•  Vision loss

•  Cavernous sinus thrombosis

•  Osteomyelitis

REFERENCES

1.  Hauser A, Fogarasi S. Periorbital and orbital cellulitis. Pediatr Rev. 2010;31(6):242–249.

2.  Baring DE, Hilmi OJ. An evidence based review of periorbital cellulitis. Clin Otolaryngol. 2011;36(1):57–64.

3.  Beech T, Robinson A, McDermott AL, et al. Paediatric periorbital cellulitis and its management. Rhinology. 2007;45(1):47–49.

4.  Upile NS, Munir N, Leong SC, et al. Who should manage acute periorbital cellulitis in children? Int J Pediatr Otorhinolaryngol. 2012;76(8):1073–1077.

5.  Georgakopoulos CD, Eliopoulou MI, Stasinos S, et al. Periorbital and orbital cellulitis: a 10-year review of hospitalized children. Eur J Ophthalmol. 2010;20(6):1066–1072.

ADDITIONAL READING

•  Chaudhry IA, Shamsi FA, Elzaridi E, et al. Inpatient preseptal cellulitis: experience from a tertiary eye care centre. Br J Ophthalmol. 2008;92(10):1337–1341. doi:10.1136/bjo.2007.128975.

•  Goldstein SM, Shelsta HN. Community-acquired methicillin-resistant Staphylococcus aureus periorbital cellulitis: a problem here to stay. Ophthal Plast Reconstr Surg. 2009;25(1):77.

•  Mahalingam-Dhingra A, Lander L, Preciado DA, et al. Orbital and periorbital infections: a national perspective. Arch Otolaryngol Head Neck Surg. 2011;137(8):769–773.

•  Yeilding RH, O’Day DM, Li C, et al. Periorbital infections after Dermabond closure of traumatic lacerations in three children. J AAPOS. 2012;16(2):168–172.

 CODES

ICD10

L03.211 Cellulitis of face

CLINICAL PEARLS

•  Periorbital (preseptal) and orbital (postseptal) cellulitis occur most commonly in children.

•  It is critical to differentiate between periorbital cellulitis and orbital cellulitis; the latter is more dangerous and can be life threatening. Orbital cellulitis typically has fever, pain with eye movement, diplopia and/or proptosis. Prompt imaging is necessary if there is a concern for orbital cellulitis.

•  CT scan of the patient’s sinuses and orbits can be used to differentiate periorbital cellulitis from orbital cellulitis.

•  The two most important predisposing factors for periorbital cellulitis are upper respiratory infections and eyelid trauma; sinusitis is more typically associated with orbital cellulitis (5)[C].